224 - RA Flashcards by Lucy Knox

Where is the primary site of RA?

Synovium

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What changes occur to the synovium in RA?

Pannus formation - thickened, inflamed
erosion of bone, cartilage and ligament
Excess synovial fluid

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How common is RA?

0.5-1% of population

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What risk factors are there for RA?

Smoking

Genetic - assoc. with HLA-DR4 and PTPN 22

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What is the usual presentation for RA?

Gradual onset, in small peripheral joints

Morning stiffness, swelling in joints + hands, symmetrical

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What is the pattern of RA joints?

Usually PIPs, MCPs and wrist

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What changes can be seen in the hand of someone with RA?

Ulner deviation of the fingers
Dorsal interosseous wasting
Swan neck deformities
Boutonnier deformity

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What can be seen on Xray in RA?

Periarticular osteopenia (looks darker)
Periarticular errosions
Reduced joint space
Ulner deviation + subluxation

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In RA what are the systemic effects it has?

Nodules - s/c gristle
Vasculitis
Cardiac (IHD, pericarditis, valvular disease)
Respiratory (Effusions, fibrosis, nodules)
Haem (Anaemia of chronic disease, thrombocytosis)
Neuro (entrapement neuropathies, atlanto-axial subluxation)
Occular (Episcleritis, scleromalacia)
Amyloidisis - builds up in tissues eg. tongue

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How do you diagnose RA?

Clincial signs
Bloods - ESR, CRP, Rheumatoid Factor, Anti-CCP
Imaging - US, Xray

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Which is better to diagnose RA - RF or Anti CCP?

Anti-CCP - more specific to RA (but not as sensitive, only 70% of RA have it)

RF is good as 80% with RA are +ve, but 10% of normal population also +ve

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What is the treatment of RA?

Analgesia
NSAIDS
Steroids
DMARDS (Methotrexate, Sulphasalazines, Leflunomide)
Biologics (anti-TNF a - infliximab, Anti CD20 - Rituximab)

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What characterises connective tissue diseases?

Inflammation, Fibrosis, Thrombosis

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What are the common symptoms of connective tissue diseases?

Fatigue, malaise, fever
Depression
Arthralgia/myalgia
Weight loss
Lymphadanopathy

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What clinical features might be found in someone with connective tissue disease?

Raynauds
Inflammatory arthritis
Skin rashes
Muscle weakness
Pleurisy
Vascular events
Recurent foetal loss

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What associations are there with connective tissue disease?

HLA

Ethnic susceptibilities

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Name 4 connective tissue diseases

SLE : systemic lupus erythematosis
Inflam muscle disease - polymyolitis or dermatomyolitis
Scleroderma
Sjorgrens syndrome

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What specific signs are there in SLE?

Butterfly rash - photosensitive
Arthritis
Oral ulcers
Alopecia 
Serositis

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What are the autoantibodies associated with SLE?

ANA (100% +ve),
ds DNA (50% +ve),
anti-sm (15%),
anti-Ro/La (20%)

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What treatment options are there for SLE?

NSAIDS
Hydroxychloroquine to myalgia
Prednisalone for arthritis

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What is scleroderma otherwise known as?

Systemic sclerosis

What are the features of scleroderma?

Fibrotic skin tightening (proximal to elbow)

Can be limited, diffuse or localised

In diffuse scleroderma what autoantibody is seen?

anti-scl 70

What are you at increased risk of with diffuse scleroderma?

Pulmonary fibrosis

Renal Crisis

What is another name for limited scleroderma? What does it mean?

``` CREST syndrome C-alcinosis R-aynauds E-osophageal dysmotility S-clerodactyly T-alangectasia ```

What autoantibodies are present in limited scleroderma/CREST?

Anti-centemere autoantibodies

What are the symptoms of Sjorgrens Syndrome?

Dry eyes + mouth | Parotid swelling

What autoantibodies are seen in Sjorgrens syndrome?

Ro (ssa) / La (ssb) autoantibodies ANA RF

Which connective tissue disease puts you at higher risk for lymphoma?

Sjorgrens

What is polymyositis?

Direct inflammation of the muscle itself | Symmetrical prox muscle weakness

What systemic problems can you see with an inflammatory muscle disease?

Heliotrope rash - around eyes and eyelids Guttrons papules - dry scaly skin on knuckles Mechanics hands - dry scaly skin on tips of fingers

What enzyme is elevated in inflammatory muscle disease?

CPK - elevated muscle enzyme

How do you treat polymyositis?

Steroids | Immunosuppressants

What is vasculitis?

Inflammation within or through a vessel wall - causing an impairment in blood flow + integrity of the vessel - haemorrhage or infarction can occur.

What is PMR and what is it associated with?

Polymyalgia Rheumatica Assoc. with GCA - Giant cell Arthritis

What are the features of PMR? What age does it affect?

Affects middle ages/ elderly Pain + stiffness in neck, shoulder, pelvic girdle. Worse in morning, improves with activity

What systemic effects are there in PMR?

Malaise, weight loss, flue-like

What blood tests are raised in Vasculitis?

ESR | CRP

What is Giant cell arthritis?

affects large vessels (with internal elastic components) eg. aortic arch and branches Causes: headaches, jaw claudication, fatigue, visual disterbances

If Giant cell arthritis is left untreated what are they at risk of?

Blindness Stroke MI Necrosis

What investigation can be done to confirm giant cell arthritis?

Temporal artery biopsy

What can be given to treat GCA?

High dose prednisolone Aspirin Osteoporosis prophylaxis

Name 4 types of small vessel vasculitis?

Wegners Polyangiitis Polyarthritis Nodosa Churg-Straus

What are the general symptoms + systemic effects seen in Small vessel vasculitis?

Malaise, fever, weight loss ``` Skin - purpura, ulcers, infarction ENT - Epistaxis, sinusitis, deafness Resp- Cough, haemoptysis, dyspnoea GI- ulcers, pain, diarrhoea Neuro - Sensory/motor impairments Cardiac - chest pain, MI Renal - Renal failure ```

What investigations are important in small vessel vasculatis?

``` Inflammatory markets (FBC, ESR, CRP) ANCA +ve - antineurophil cytoplasmic antibody ``` (can look for specific antigen involvement, eg. PR3 in wegners)

What are the core treatment approaches for small vessel vasculitis?

Induce remission - steroids, cyclophosphamide, biologics (anti-TNFs or rituximab) Maintain remission - Azathioprine, methotrexate, biologics, mycophenolate mofetil (immunosuppressant)

What is Wegner's / Granulomatous polyangiitis

Destructive vasculitis, damages midline structures: nose, trachea, lungs, eyes, glomerulonephritis Assoc with ANCA PR3

What is Polyarthritis nodosa?

``` Rare vasculitis, aneurysms in medium sized vessels Rash, mononeuritis multiplex High BP Testicular pain GI infarction ```

What is microscopit polyangiitis?

Rare vasculitis | ANCA MP0

What is churg strauss?

Weakly ANCA associated vasculitis Eosinophilia Linked to adult onset asthma

What is antiphospholipid syndrome?

Recurrent vascular thrombosis, pregnancy loss and thrombocytopoemia. Assoc. with antiphosopholipid antibodies Treat with warfarin.